This month’s issue of Pediatrics features studies from Baams1 and Becerra-Culqui et al,2 in which they contribute to the ever-growing body of literature that characterizes psychosocial disparities faced by lesbian, gay, bisexual, transgender, questioning (LGBTQ), and gender nonconforming youth. Authors of several studies have previously described the psychosocial realities of these youth that include, but are not limited to, depression, anxiety, nonsuicidal self-injury, suicidality, homelessness, and substance use.3,–5 However, in 2 studies in this issue, both with the strength of describing large population-based samples, authors confirm the dismal psychosocial disparities experienced by these youth and provide novel information that should embolden health care providers to better identify such youth in their practices, assess risk factors, and offer support options that may not only promote resilience but may also be lifesaving.
There has been growing evidence in which stress associated with cumulative adverse childhood experiences has been linked with negative immediate and lifelong effects on health.6 In Baams’1 cross-sectional study, she innovatively examined patterns of these adverse experiences in a large cohort of LGBTQ and gender nonconforming adolescent students. Adverse experiences that were studied included having a parent(s) in prison, living with a problem drinker, living with a drug abuser, experiencing psychological abuse, experiencing physical abuse, witnessing domestic violence, experiencing sexual abuse by nonfamily, and experiencing sexual abuse by family. In Baams’1 study, she not only demonstrated an increased cumulative exposure to childhood adversity in LGBTQ and gender nonconforming youth compared with their heterosexual and cisgender peers but also elucidated distinct patterns of childhood diversity. These patterns characterize how the adverse experiences may cluster together, and in the study, Baams found 4 profiles: no or low adversity, polyvictimization (experience all forms of adverse experiences), psychological and/or physical abuse, and household dysfunction. Overall, LGBTQ and gender nonconforming youth were more likely to have profiles other than the no or low adversity designation. Understanding the types of trauma and adverse experiences for which LGBTQ and gender nonconforming youth are at risk could be crucial for screening of risk factors and providing appropriate services. Additionally, although LGBTQ and gender nonconforming youth had higher rates of adverse experiences, it must be noted that 85% of birth-assigned male youth and 80% of birth-assigned female youth were placed in the no or low adversity profile; therefore, clinicians should be careful not to assume that all sexual minority and gender diverse youth have had adverse childhood experiences.
In the cross-sectional study by Becerra-Culqui et al,2 the authors specifically focused on a cohort of >1300 transgender and gender nonconforming youth (age 3–17 years), not necessarily in specialized care, enrolled in a large health care system. They found a high prevalence of anxiety, depression, and attention-deficit disorders. Of particular concern was the high frequency of suicidal ideation and self-harm in the adolescents, underscoring the importance of urgent evaluations and interventions that may be lifesaving.
How can the salient findings in Baams’1 and Becerra-Culqui et al’s2 studies influence clinical practice for pediatricians? Although the mechanisms linking sexuality and gender identity and the complex psychosocial issues described in these reports are incompletely understood, in these studies, researchers reinforce the need for clinicians to assess for risk factors for poor psychosocial outcomes that disproportionately affect LGBTQ and gender nonconforming youth. Even before such risks factors can be assessed, a first crucial step is creating clinical environments that promote these youth feeling comfortable with disclosing their sexuality and gender identity. In addition, from residency through continuing medical education, providers themselves need the tools, skills, and guidance to feel comfortable and confident in their ability to assess for risk factors for poor psychosocial outcomes that disproportionately affect these youth.7,8 Only by identifying LGBTQ and gender nonconforming youth and appropriately screening them can they be provided with specific, potentially lifesaving supports that may be needed, including gender-affirming treatments for transgender youth, referral to a mental health provider, family engagement, and referrals to community programs for peer engagement.
Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.